Failure to Monitor and Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement procedures to identify the risk for elopement and adequately monitor a cognitively impaired resident who left the facility without staff knowledge. The resident, who had a history of severe cognitive impairment, was found outside the facility by the Assistant Director of Nursing (ADON) and was followed in a car until stopped. The resident had previously been assessed as not at risk for elopement, despite having a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment and expressing a desire to leave the facility. The resident's care plan was updated to include a wander alert bracelet only after the incident occurred. The facility's policy on missing residents and elopement was not followed, as there was no formal investigation conducted, and the incident was not considered an elopement by the Director of Nursing (DON) and the Regional Nurse. The Maintenance Director was unaware of any issues with the door alarms, and the facility did not determine through which door the resident exited. Interviews with staff revealed that the resident was not familiar to the DON, and the incident was not reported as an elopement because the resident was followed by the ADON. The Occupational Therapist had previously recommended distant supervision for the resident's use of an electric scooter, but no elopement evaluation was conducted when the resident began using the scooter. The facility's failure to recognize and address the resident's elopement risk contributed to the deficiency.
Plan Of Correction
1) Resident #1 elopement evaluation completed. 2) Current residents had elopement evaluations completed. 3) Systematic Change: Residents will be evaluated for elopement on admission, readmission, quarterly, and with a change in conditions. Residents identified for an electric scooter will have an elopement evaluation completed prior to receiving the scooter. The Regional Director of Clinical Services reeducated the DON regarding the completion of a thorough investigation. The DON educated staff regarding nursing communication for residents receiving electric scooters. The ADON reeducated current staff regarding identifying residents at risk of elopement. New staff will be educated during orientation. 4) The Facility DOR/Designee will conduct a quality review of residents receiving electric scooters for assessment of use to ensure nursing communication is completed so that the completion of elopement evaluations can be initiated weekly for 4 weeks, then every 2 weeks for 2 months, then monthly. Results of these audits will be presented to the QAPI committee until the committee determines substantial compliance has been achieved. The Facility ADON/Designee will conduct a quality review of 10 residents for completion of elopement evaluations on admission, readmission, quarterly, significant change, and prior to approval of electric scooters weekly for 4 weeks, then every 2 weeks for 2 months, then monthly. Results of these audits will be presented to the QAPI committee until the committee determines substantial compliance has been achieved.